What doctors wish patients knew about getting a cesarean section

A cesarean section, or C-section, is a surgical procedure used to deliver a baby. The doctor makes an incision in the mother's abdomen and then another in the uterus to deliver the baby. It may be planned in advance for medical reasons, such as when the baby is in a breech position, or if the mother or baby has certain health conditions. It also may be performed unexpectedly during labor if complications arise. 

While cesarean delivery can be lifesaving for both mother and baby, it is a major surgery and may carry more risk and a longer recovery than vaginal birth. Understanding when and why a C-section might be necessary can help expectant parents have educated conversations with their physician about childbirth.

In 2023, 32.3% of live births were cesarean deliveries in the U.S. while 67.7% were vaginal deliveries, according to the National Center for Health Statistics. Certain stressors in patients’ lives, such as having low income or limited access to prenatal care, can potentially lead to increased C-section rates. 

There are many factors that may require a C-section delivery, but pregnant women are more like to undergo a C-section if they are over 30, have a higher body mass index, are pregnant with multiple babies or of African American descent. Additionally, women 30 or older and those who are having their first child also have higher rates of C-sections.

The AMA’s What Doctors Wish Patients Knew™ series gives physicians a platform to share what they want patients to understand about today’s health care headlines.

In this installment, Cindy Celnik, MD, took time to discuss C-sections and what women should know. She is currently the assistant national medical director of HCA Healthcare Women’s Services. More than 215,000 babies are delivered annually across HCA Healthcare’s network of hospitals, and the organization uses data from these births to look for insights to improve maternal and neonatal outcomes. 

HCA Healthcare is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

“A C-section is a surgical procedure where an incision is made in the woman’s belly and it’s typically performed when a vaginal delivery is either not safe or not possible,” Dr. Celnik said, noting that “a C-section is the most common major surgery performed in the United States.”

“Nearly 1.2 million women have their babies by C-section every year, which accounts for about one-third of all pregnancies,” she said. 

“A cesarean section is often needed when a vaginal delivery is unsafe or not possible to complete. For when it is not safe to do a vaginal delivery”, said Dr. Celnik. “What falls under that category—most commonly—is potential distress of the baby indicated by the fetal heart tones, prompting recommendation of your physician to do a C-section to keep the baby safe.”

Cindy Celnik, MD

“Another reason—and this is much rarer—is that a C-section needs to be completed because of an immediate threat to the health of the mom or the baby,” she said, “such as significant bleeding (hemorrhage) or umbilical cord prolapse (cord falling out of the uterus).” 

“There are also situations where a vaginal delivery simply isn’t possible. One is stalled labor or not progressing in labor,” Dr. Celnik said. “And that is when the cervix is not dilating—meaning not opening—or the baby is not descending through the birth canal. In these cases, there isn’t another way to deliver the baby except via a C-section.”

“Another very common reason for C-section is the baby’s position,” she said. “For example, if the baby is breech or transverse, meaning not laying head down within the uterus.”

“At HCA Healthcare, we really wanted to help answer the question of when the right time for a C-section is,” said Dr. Celnik. “We conducted a survey in 2007, which included over 17,000 births in 27 HCA Healthcare hospitals throughout the United States. 

“We were looking at the effectiveness of different approaches to a reduction in elective early term deliveries or the effect of such policies on newborn intensive care admissions and stillbirth rates,” she added. “This research was carried out in partnership with the March of Dimes at the request of the American College of Obstetrics and Gynecology, or ACOG, which is the organization that governs and sets standards for ob-gyns.”

“This study revealed that elective delivery prior to 39 weeks resulted in worse outcomes for babies,” Dr. Celnik said. “Subsequently, CMS—which is the Centers for Medicare & Medicaid Services, a federal agency that sets health care regulation and policy—created a quality measure that states that elective deliveries scheduled prior to 39 weeks should not be done unless there’s a medical indication.”

“That’s big—to have governing and regulatory bodies in obstetrics stand behind our study. And subsequently, the reduction of early elective deliveries has just become standard practice,” she said. “It's standard of care in hospitals in the United States, and many medical organizations use this to support and promote this guideline to help ensure great outcomes for both moms and babies.”

To reduce the risk of complications associated with early-term deliveries, ACOG also recommends that elective cesarean delivery should not be performed before 39 weeks. 

“Recently, HCA Healthcare also worked with March of Dimes to conduct a study in which they interviewed physicians and compiled their insights.,” said Dr. Celnik. “The information gathered from these interviews was then analyzed to identify practices for reducing unnecessary C-sections among nulliparous, term, singleton, vertex—essentially first-time, low-risk, single, head-first position, also called NTSV—births. 

“That study highlights common themes, including factors at both the physician and hospital levels, that can influence C-section rates,” she added, noting “we used these insights to create educational videos for our physicians and nurses.”  

“Both the duration of hospitalization and the postpartum recovery periods are longer, as you may expect, in the case of a cesarean and compared with vaginal birth. Recovery from a C-section is six to eight weeks to feel almost completely recovered. For a vaginal delivery, it’s two to four weeks,” said Dr. Celnik. “In addition to that—and very importantly—the risk of severe maternal complications is three times higher after a C-section compared to a vaginal birth.

“This includes significantly higher risk of complications such as infection, bleeding and blood clots,” she said, noting “there are also some that are a little less common, including cardiac arrest, wound disruption and hysterectomy.”

“There are also increased risks of placental attachment problems such as placenta previa and placenta accreta. These are higher in pregnancies after a C-section and the risk increases with the number of C-sections you have,” said Dr. Celnik. “What this means is that the placenta attaches in a way that can cause life-threatening bleeding or other complications during delivery necessitating emergent removal of the uterus in many cases.”

Meanwhile, “a baby born by C-section may have more breathing problems and need to stay longer in the hospital. They get admitted to the NICU more commonly,” she said. “In addition, there’s some research that says that babies born by C-section may have a higher chance of developing asthma up to 12 years old.”

“C-sections are typically associated with more pain and discomfort as well as an increased healing time because there's a large incision in the belly compared to that of a person who's had a vaginal delivery,” Dr. Celnik said. “Patients who had a vaginal delivery usually move around and resume normal activities sooner than a C-section patient because they don't have limited mobility or lifting associated with a vaginal delivery.

“Breastfeeding can also be a little bit more challenging due to mobility limitations,” she added. 

“One of the most important advancements has been the use of enhanced surgical recovery, or ESR protocols, specifically tailored to C-sections,” said Dr. Celnik. “These were initially developed for colorectal surgeries in Europe many years ago, but these protocols have been adopted for various other surgeries, including c-sections, to enhance the patient recovery and to reduce the risks.

“In 2020, I was the chief medical officer at The Woman's Hospital of Texas in Houston, which was one of the largest delivery facilities in HCA Healthcare delivering more than 11,000 babies annually. The Woman’s Hospital of Texas implemented ESR for C-sections and established ourselves as an early adopter of this progressive approach here in the United States,” she explained. “This successful process improvement involved standardized protocols for all C-section patients which led to a significant reduction in length of stay at the hospital as well as a reduction in opioid usage.”

“Recognizing this, HCA Healthcare’s leadership team has since expanded this initiative across our organization to enhance recovery and optimize patient care for all of our C-section patients,” Dr. Celnik said. “Now, in 2025, it is more common to see this at hospitals outside of HCA Healthcare, but it’s still not the norm.” 

“The most common long-term implications include adhesions, which means there are bands of scar tissue inside the belly because you've had major surgery,” said Dr. Celnik, noting “they're common after C-sections and they can become more severe with each further surgery that you have.

“These adhesions can make future abdominal surgeries more challenging. It can increase the risk of bladder or bowel injuries, which are the surrounding structures,” she said. “And again, it’s important to know that women with multiple C-sections are also at risk for other things, including the placental attachment disorder known as placenta accreta.”

Additionally, “you have a higher risk of developing incisional hernias, meaning a hernia around where the incision is, as well as localized numbness,” Dr. Celnik said. “In fact, some people have long-term numbness of that area.” 

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“There are many factors that can impact the likelihood of a successful vaginal birth after a cesarean section, also called a VBAC,” said Dr. Celnik, emphasizing that “it’s really important that your doctor individualize this conversation and thoroughly reviews the specific risk factors that are relevant to you and your medical history before you decide on this option.

“Some common primary factors to consider include the number of C-sections you’ve had, the reasons why you’ve had these C-sections and whether or not you’ve ever had a vaginal delivery before,” she said. “In addition, there is one thing that must be present.

“It is essential that the hospital you select to deliver at has the capability to conduct a trial of labor after C-section, which means that an in-house team is readily available in case of an emergency,” Dr. Celnik added.

“A lot of people talk about the joy of motherhood as we all should. It's one of the best things,” Dr. Celnik said. “But not a lot talk about the fact that it takes your body time to heal, especially from a C-section, mentally and physically.

“So, expecting that is important and expecting that not every minute is going to be rosy and picture perfect,” she added. “It's really important to expect that there's going to be hard times, including times where we don't get enough sleep. And we all know that sleep deprivation is very challenging.”

“Make sure you rely on your network of support—your family, your friends, your OB team,” Dr. Celnik said. “Don't be afraid to reach out. Problems occur if you're afraid to reach out. All of these support structures that you have are there to support you and your new baby.”